P - 44468Building { MECHANICAL I Permit No.:
Inspections RESIDENTIAL APPLICATION Received B�_�,__
�63-s�2-3604 CITY OF FRIDLEY '
763-502-4977 FAX EFFECrivE,-i-zo>> ��������
DATE ��'"�%'ZO�/ Y�OURE-MAILADDRESS SC`�y"h'f'�(tpluSM�C�iaNrcu.I{MN � COl1-t
SiTE ADDRESS �3C10 �p 1 �L /�Q t/� / V �� _
THIS APPLICANT IS:
PROPERTY
OWNERI
TEIVANT
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE
LICENSE WITH
APPLICATION
PERMIT TYPE
TYPE OF WORK:
Q OWNER �ONTRACTOR
NAME: �v co p So.r.io e, u.i C�"
ADDRESS: �3°f O �� "��" U R /� � C1TY Tr�d-�
PHONE: %iv3'S�I�' /
COMPANY NAME: 7�' /'I eCi7G�N � CCt/i �Nc .
CONTACT PERSON: _�f'O �� /'6 /y► a N�P r
AT�N ZIP
STATE LICENSE # EXP DATE �,,�g
ADDRrESS: Z �_.�CJ �. `,�K.J� IL �G� CITY �j�{�/,�j//'i � STA� � ZIP��x1C3
PHONE 7�3"'(p9�"''S2Z FAX
�i INGLE FAMILY ❑ TWO FAMILY
�'AEW ❑ REPLACEMBNT
DETAILED DESCRIPTION OF WORK
❑ TOWNHOUSE
❑ ALTERATION/REMODEL
FEES ARE BASED ON $10.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW)
PROVIAE HEAT LOSS CALC'S PER MANUAL J 2006 ASHRAE HANDBOOK.
Equipment Instailed MFG: MODEL: S[ZE/BTU
MFG: MODEL: SIZE/BTU
MFG: MODEL: S[ZE/BTU
A/C $25.00 FIREPLACE (GAS) $15.00 GAS RANGE/OVEN $10,00
AIR TO AIR EXCHANGEER $ I S FIREPLACE (WOOD) $35.00 NEW GAS GRILL $10.00
BOILER $35.00 FURNACE $35.00 GAS UNIT HTR $10.00
_CHIMNEY L[NER $10.00 GAS DRYER $10.00 POOL HEATER $35.00
_DUCT WORK $10.00 �GAS PIPING $10.00 VENT(LATOR $15.00
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID UNTIL PROCESSED
I hereby apply for a building permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only an application for a permit and work is not to start without a permit; that the work will be in accordance with the
approved plan in the case of all work which requires review and approval of plans.
SIGNATURE OF APPLICANT �iCJ��i► PRINT NAME �O� ��/JYNa.`L�� DATE �� ���QII
AL
TURE
DA
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604 FAX: 763-502-4977